Published in the June/July 2004 issue of Today’s Hospitalist
At the 2004 annual meeting of the Society of Hospital Medicine in New Orleans, one of the nation’s leading experts on improving the quality of health care challenged the nation’s hospitalists to use their unique positions to tackle what he considers the most pressing problem in medicine today: the number of unnecessary deaths that occur daily in the nation’s hospitals.
Physicians may disagree about the precise numbers of errors taking place, explained James L. Reinertsen, MD, but few would argue that thousands of people who are admitted to the hospital die unexpectedly and needlessly during their stay. Dr. Reinertsen is a rheumatologist who heads The Reinertsen Group, a consulting firm that works on health system safety issues.
As Dr. Reinertsen told physicians attending the meeting in April, some in health care argue for the low end of the estimate made by the Institute of Medicine in its groundbreaking 1999 report “To Err is Human.” That report said that between 44,000 and 98,000 U.S. citizens die each year from preventable deaths.
Dr. Reinertsen, however, said that he and others estimate that 10 times that number of Americans die needlessly in the hospital. He said that studies have shown that, on average, more than 40 percent of a hospital’s deaths occur in patients who were well enough at the beginning of their hospital experience to have been admitted to non-intensive care wards. These patients are expected to leave the hospital treated, perhaps cured, and certainly alive.
“I believe we need to aim high, and reducing the hospital standardized mortality rate is as good as we’ve got,” Dr. Reinertsen said during his address. He added that hospitalists are in an ideal position to tackle this premier patient safety problem.
Changing low expectations
Dr. Reinertsen is no stranger to the hospital medicine movement. As CEO of Park Nicollet Health Services in Minneapolis, he oversaw the creation of one of the nation’s first hospitalist programs in the 1980s. In the 1990s, he served as CEO of CareGroup and Beth Israel Deaconess Medical Center in Boston, another institution with experience in hospital medicine.
“You work across the boundaries of lots of different parts of the hospital, and you see the kinds of things others don’t,” he told the hospitalists in the audience. “Therefore, you have responsibility to do something about it. There’s an opportunity, but with that goes a responsibility. What are you going to do about it?”
That challenge was echoed by one of the founders of the hospital medicine movement. In his address on the state of hospital medicine, Robert M. Wachter, MD, head of the hospitalist program at the University of California, San Francisco (UCSF), urged his colleagues to adopt patient safety as their profession’s No. 1 mission.
“What we do in patient safety may turn out to be the most enduring legacy of our entire field,” he said. Dr. Wachter and UCSF hospitalist Kaveh Shojania, MD, are the authors of “Internal Bleeding,” a new book on the epidemic of medical mistakes.
Most importantly, Dr. Wachter said, hospitalists have to help change medicine’s current “culture of low expectations.” This allows health care providers to simply accept the fact that errors will occur, and to think that there is little or nothing they can do. He also said that hospitalists need to function as the people in hospitals who make true teamwork happen.
And while Dr. Wachter urged his colleagues to lead the charge for more information technology, he said they need to recognize that computers alone will cure very few of the deeper, more systemic problems of communication and a lack of protocols and standards.
Standardize and simplify
Dr. Reinertsen challenged hospitalists to “standardize and simplify” common care processes so that they can focus more attention on practicing the “science” of medicine. Patients expect this, he said, and they are shocked when they discover how much variation is tolerated in simple processes of care, particularly when there is clear evidence that one way is better and safer than another.
The reason doctors have been losing some autonomy to payers and the public, he said, is that society sees this kind of practice variation as “looking like the Tower of Babel” and harming them.
The fact that there is so much variability in how doctors practice medicine “even how they do or don’t do simple things that evidence proves is effective “is “a breeding ground for errors,” he said. There is no argument in favor of giving physicians so much autonomy that they can make decisions that are not backed up by evidence “and that may harm and even kill patients.
For instance, he said, when five simple things “from appropriate deep venous thrombosis prophylaxis to elevating the patient’s head “aren’t ordered for patients on ventilators, the evidence clearly shows infection rates increase.
“A lot of people are getting infections on ventilators because evidence is not being used,” he said.
The public does not “and should not “understand this situation, Dr. Reinertsen contended. “If we practice the science of medicine as a team,” he added, “society might give us the privilege of practicing the art of medicine as individuals.”
A simple exercise
Dr. Reinertsen urged hospitalists interested in improving mortality rates to start with a simple exercise, one that he said will shed light on the scope of the problem at their own institution.
To get started, plot the last 50 deaths that occurred in your hospital into a simple chart with four boxes. All patients fall into one of four categories.
The first contains patients admitted to the ICU for palliative care. The second category lists patients admitted to a floor other than the ICU for palliative care. (Patients in these two groups, he explained, are generally expected to die.)
In the other two categories, he said, list patients who were not expected to die during their hospitalization. One box should list patients admitted to the ICU; the other should list patients admitted to non-intensive care beds.
When most hospitals complete that exercise, he explained, they typically find that about 40 percent of all their in-hospital deaths occurred in the hospital’s least sick patients. (Another 40 percent tend to fall into the other category of patients not expected to die but who were sick enough to have been admitted to intensive care units.)
Dr. Reinertsen recommended that hospitalists focus their attention only on patients who are expected to survive. Go back and study these patients’ charts to discern what happened, he said. Then design an action plan to make sure others don’t suffer the same fate.
Attacking common problems
Hospitals that consistently do this exercise find some common causes of what went wrong, he said. Those factors include inadequate nurse staffing, poor nurse-doctor teamwork, poor doctor-doctor communication, lack of medical emergency teams who can rush to a patient’s bedside and intervene before a patient codes, and a lack of real hospitalists on site to catch problems early and to coordinate care.
Dr. Reinertson said that studies have found no relationship between expenditures and the chance a patient will emerge from a hospital alive or dead.
He also noted that he is currently involved in a study that is examining what’s different about the hospitals in the country that have the highest mortality rates and the ones that post the lowest. “One of our hypotheses is that hospitalists make a difference,” he said.
“The bottom line is that each hospital’s mortality ‘dot’ (as plotted on a chart) contains needless deaths that we can do something about,” Dr. Reinertsen said. “I think we should adopt the goal of no needless deaths.”
To achieve that goal, Dr. Wachter told the group of hospitalists, medicine must move from a culture of blame where the most important question asked after a mistake involves identifying who caused the error. U.S. health care must instead adopt a system view that asks what went wrong.
“We need to change scripts, not actors,” he said.
Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.